AHIP MODULE 3
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. What would you like to do?
Mrs. Fiore was in the Army for 35 years and
is now retired. She has drug coverage through the VA. What issues might she
consider with regard to whether to enroll in a Medicare prescription drug plan?
- could compare the coverage to see if the Medicare Part D plan offers better
- benefits and coverage than the VA for the specific medications she needs and
- whether any additional benefits are worth the Part D premium costs
Mr. Jacob understands that there is a standard Medicare Part
D prescription drug benefit, but when he looks at information on various plans
available in his area, he sees a wide range in what they charge for
deductibles, premiums and cost sharing. How can you explain this to him?
- Part D drug plans may have different benefit structures, but on average, they
- must all be at least as good as the standard model established by the
Mr. and Mrs. Vaughn both take a specialized multivitamin
prescription each day. Mr. Vaughn takes a prescription for helping to regrow
his hair. They are anxious to have their Medicare prescription drug plan cover
these drug needs. What should you tell them?
- prescription drug plans are not permitted to cover the prescription medications
- the Vaughns are interested in under Part D coverage, however, plans may cover
- them as supplemental benefits and the Vaughn’s could look into that possibility
What types of tools can Medicare Part D prescription drug
plans use that affect the way their enrollees can access medications?
- D plans do not have to cover all medications. As a result, their formularies,
- or lists of covered drugs, will vary from plan to plan. In addition, they can
- use cost containment techniques such as tiered co-payments and prior
Since 1999, Mrs. Pagel has had a Medigap policy that covers
drugs. This year she received a letter from her Medigap insurer telling her
that her Medigap drug coverage is not "creditable." She wants you to
explain what this means and what she should do. What should you tell her?
- letter is letting her know that her Medigap drug coverage is coverage that does
- not expect to pay, on average, at least as much as Medicare’s standard Part D
- coverage expects to pay. If she signs up for a Medicare prescription drug plan
- now, she may have to pay a premium penalty
Mrs. Allen has a rare condition for which two different brand
name drugs are the only available treatment. She is concerned that since no
generic prescription drug is available and these drugs are very high cost, she
will not be able to find a Medicare Part D prescription drug plan that covers
either one of them. What should you tell her?
- prescription drug plans are required to cover drugs in each therapeutic
- category. She should be able to enroll in a Medicare prescription drug plan
- that covers the medications she needs
Mr. Culotta has a small savings account. He would like to pay
for his monthly Part D premiums with an automatic monthly withdrawal from his
savings account until it is exhausted, and then have his premiums withheld from
his Social Security check. What should you tell him?
- general, he must select a single Part D premium payment mechanism that will be
- used throughout the year
Mr. Carlini has heard that Medicare prescription drug plans
are only offered through private companies under a program known as Medicare
Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up
for an MA product, but he also wants prescription drug coverage. What should
you tell him?
- Carlini can stay with Original Medicare and also enroll in a Medicare prescription
- drug plan through a private company that has contracted with the government to
- provide only such drug coverage to eligible Medicare beneficiaries
Mrs. Andrews was preparing a budget for next year because she
takes quite a few prescription drugs, she will reach the coverage gap, and
wants to be sure she has enough money set aside for those months. She
received assistance calculating her projected expenses from her daughter who is
a pharmacist, but she doesn’t think the calculations are correct because her
out-of-pocket expenses would be lower than last year. She calls to ask if
you can help. What might you tell her?
- would not be unusual for her costs to be a bit less because each year until
- 2020, an enrollee’s share of the drug costs in the coverage gap are less
All plans must cover at least the standard Part D coverage or
its actuarial equivalent. What costs would a beneficiary incur for prescription
drugs in 2013 under the standard coverage?
- Part D coverage would require payment of an annual deductible, 25% cost-sharing
- up to the coverage gap, a portion of costs for both generics and brand-name
- drugs in the coverage gap, and co-pays or co-insurance after the coverage gap
What would you like to do?
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